Baby Don’t Cry: Evaluation of Prolonged, Unexplained Crying in Infants
The differential of the infant presenting with unrelenting and excessive crying can range from colic to more serious conditions. A complete physical examination—including removal of the patient’s diaper—can uncover many of the more serious conditions.
The authors review the scope of normal crying, as well as the “don’t miss” differential diagnoses requiring acute management.
risk factor for toe tourniquets, and the use of mittens is similarly linked to finger tourniquets.7,12
The crying or irritable infant merits a thorough examination of all digits and external genitalia in search of constricting bands and resultant tissue swelling. If the tourniquet has gone unnoticed over time, severe swelling, embedding of the thread, or re-epithelialization of the skin over lacerated tissue may obscure the band and make simple removal impossible. In cases when the constricting band cannot be directly unwound, treatment options for a hair tourniquet include application of a depilatory agent (eg, Nair), which has been shown to effectively dissolve the hair within 8 minutes.13 If a severe laceration is present and the thread cannot be removed by unwinding, the depilatory agent should not be applied to open tissue; instead, the clinician should perform a dorsal incision of the toe or finger to remove the constricting material in its entirety.
Testicular Torsion
Testicular torsion is a common urologic emergency in the male pediatric population, with up to 12% of all cases occurring within the first year of life. It should be considered in any infant who develops acute, prolonged, unexplained crying. Eighty-five percent of infants with torsion between 1 and 12 months old will present with irritability, and 92% will present with a tender scrotal or inguinal mass14 that may go unnoticed by the parents. This possibility alone is a compelling reason to remove the diaper of an infant with prolonged crying and to perform a thorough physical examination.
While testicular deformity or a high-riding testicle can be difficult to assess on a crying baby, any scrotal enlargement, tenderness, or color change merits an emergent urology consult—and likely ultrasound imaging with Doppler sonography. Efficient and rapid management of infants with testicular torsion is essential as the testicular salvage rate is historically very poor in this population.15
Inguinal Hernia
The reported incidence of pediatric inguinal hernia is between 0.8% and 4.4%, with most patients presenting with a chief complaint of inguinal swelling. Inguinal hernias alone are symptomatic in up to 25% of infants and may present as prolonged crying.16 In these cases, inguinal hernia surgery is usually scheduled as an elective outpatient procedure. Serious issues arise when the bowel becomes edematous and incarcerated in the hernial sac, which can lead to ischemic necrosis and intestinal perforation, intestinal obstruction, and gonadal necrosis.
More than half of all cases of pediatric incarcerated hernias occur within the first 6 months of life. Infants younger than age 12 months—especially neonates—have a more severe and a higher incidence of complications related to incarcerated inguinal hernias than the rest of the pediatric population. In a recent study, one third of newborn patients were diagnosed with incarceration as their initial presentation of an inguinal hernia.17 This is another reason to remove the patient’s diaper and perform a complete physical examination on any infant presenting with acute, unexplained crying. An incarcerated inguinal hernia will likely be identified as a tender, firm, inguinal or scrotal mass with overlying swelling or discoloration and is a surgical emergency if it cannot be reduced manually.
Nonaccidental Trauma
Emergency physicians must maintain a high index of suspicion for nonaccidental trauma in pediatric patients. Studies demonstrate that 95% of serious intracranial injuries and 64% of all head injuries in infants younger than age 12 months are the result of physical abuse. Equally discouraging is the finding that as many as 75% of child abuse cases presenting to EDs are unrecognized.18,19 Infants presenting with excessive crying have elevated risk for nonaccidental trauma both because their crying may be a result of injuries sustained from physical abuse and also because their prolonged crying itself may have been a precipitating factor in nonaccidental trauma.
Stress predisposes a caregiver to child abuse and is particularly important to identify when evaluating an infant with prolonged crying and also when providing guidance to the parents of a child with symptoms of infantile colic. Additional signs of possible nonaccidental trauma include an inconsistent history, a delay in seeking medical care, inappropriate affect of the caregiver, and an injury that is not well explained by the caregiver’s history or is incompatible with the developmental stage of the child.
Other Causes
While there are no specific laboratory tests required for the diagnosis of the abovementioned common neonatal causes of acute, prolonged crying, the EP must always consider life-threatening conditions in the inconsolable or irritable infant, including dehydration, early shock, meningitis, and a surgical abdomen. The pursuit of an appropriate workup for these diseases, accompanied by an awareness that infants may present atypically (eg, hypothermic instead of febrile) will often lead to comprehensive laboratory studies.
